Palliative Care or Hospice? Flipping the Classroom for 1st Year Pre-clinical Medical Students With Interactive Online Content.

Background: More than 5 million people in the USA suffer from heart failure (HF). Palliative care (PC) is both a clinical subspecialty and overall approach to care that focuses on promoting seriously ill patients and their family’s quality of life. PC takes several forms, including consultation by a PC specialist, or attention to palliative domains by a non-PC specialist (aka “primary” PC). Despite guidelines calling for the integration of PC in HF, specialty PC remains underutilized. Patient preferences regarding primary vs specialty PC are unknown. Objective: To identify patient knowledge and perceptions regarding how primary and specialty PC could complement usual HF management, as well as barriers preventing PC utilization. Methods: We recruited individuals with NYHA class II-IV HF from general medicine wards and an outpatient advanced HF clinic, both at an academic quaternary care hospital. We conducted semi-structured interviews addressing: (1) patient-perceived physical, emotional, social, and decision-making needs; (2) perception, knowledge, and preferences regarding PC; (3) barriers and facilitators to PC. To understand patient preferences regarding primary vs specialty PC, in the interview guide, we conceptualized PC into 5 domains: physical, emotional, spiritual and social aspects of care, and advance care planning. For each domain, participants discussed unmet needs, and preferences about whether the needs would be best met by their existing cardiology team or a PC specialist. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative technique. Results: We interviewed 28 patients; 82% were white, 61% were >60 years, and 64% were male. 43% of participants had ejection fractions <30%, and 64% were of NYHA classes III or IV. Symptom burden was high and a source of dissatisfaction; yet, few believed that their disease management was suboptimal, often citing a sense of resignation that symptoms are inevitable in HF. We heard mixed and often incorrect understandings of PC (and its distinction from hospice). Once misperceptions of PC were corrected, respondents expressed variable preferences for specialty vs. primary PC. Proponents of primary PC cited trust and rapport in their existing clinicians, HF-specific expertise, convenience, and cost. Alternatively, participants preferring specialty PC involvement cited expertise in symptom management, addressing caregiver concerns, reduced time constraints, and a comprehensive non-HF-exclusive approach to care. Conclusion: We frequently identified limited and often incorrect understanding of PC. Though once corrected, patients articulated variable preferences for primary vs. specialty PC integration into their existing HF care. Research is needed to identify means of increasing primary and specialty PC delivery in HF in a manner that reflects patient preferences.

The teaching and learning activities of any undergraduate curriculum will have a specific set of learning outcomes that should be successfully achieved by the students. The balance between the workload of a student and the available time to achieve the learning outcomes plays a major role in achieving these learning outcomes, as well as a good student satisfaction score and excellent final grades for that particular module (Whillier & Lystad, 2013). In a traditional educational experience, a teacher stands in front of the classroom, delivers a lecture to a group of students, who sit in rows, quietly listening to the lecture and taking notes. At the end of the lecture, students are given homework or an assignment to be completed outside of the classroom environment. This characterises the principle of “sage-on-the stage”, and is synonymous with the present day term of teacher-centered learning. This is also referred to as the transmittal model (King, 1993), which assumes that the students are passive note-takers, receivers of the content or accumulators of factoids (Morrison, 2014). Usually, the teacher does not have time to interact with the students individually during the class (Hamdan, McKnight, McKnight & Arfstorm, 2013), thus neglecting those students who do not understand the lecture. The traditional didactic way of teaching is primarily unidirectional and consists of limited interactions between the source of knowledge (teacher) and the passive recipients (students). One of the main challenges faced by lecturers is the overload of academic content that needs to be taught in a relatively short period of time. Equally, the main challenge faced by the students is loss of interest or motivation to learn within the stipulated period of time (Prober & Khan, 2013). The traditional way of teaching, therefore, discourages the students from active learning and critical thinking. There is also increasing pressure from accreditation institutions, which demand “an ability to communicate effectively”, “an ability to identify, formulate and solve problems”, and “an ability to function on multidisciplinary teams” (Bishop & Verleger, 2013). As such, there is a need to transform the current pedagogical strategies, in order to enhance active learning in a more effective way (Al Faris et al., 2013). Synthesis of research on the effectiveness of lectures shows that lectures are not very effective for teaching and developing values or personal development, and may only be effective for the sole goal of transmitting information (Bligh, 2000). Taking these points together, it is important to explore methods that have the potential to maximise the use of classroom time and transform the classroom into a platform for teacher-student interactions and critical thinking (Rui et al., 2017). Numerous factors have cumulatively led to several challenges for traditional teaching in health professional education (HPE), including the availability of digital technologies, digitally-empowered learners, the prolific expansion of courses, the amount of factual knowledge that has accumulated in the courses, prolific growth of health knowledge, advancement in healthcare disciplines, and investment into the scholarship of teaching and learning. To this end, newer delivery systems encompassing active learning in HPE have been developed. Studies have reported that active participation is an effective method to improve learning and understanding (Freeman et al., 2014; McCoy et al., 2015). Thus, to enhance interaction during their learning, there are educational strategies, which promote active learning in traditional lectures by engaging students in doing things and encouraging them to think about what they are doing. A classic example of active learning is a think–pair–share discussion, in which a student thinks individually for a moment about a question posed on the lecture, then pairs up with a classmate to discuss their ideas, and subsequently shares their answer with the entire class (King, 1993). There are various modifications which can be incorporated into traditional lectures that enable active learning in the classroom, for instance; (a) the feedback lecture, which consists of two mini lectures separated by a small-group study session built around a study guide, and (b) the guided lecture, in which students listen to a 20- to 30-min presentation without taking notes, followed by their writing for 5 min on what they remember, and spending the remainder of the class duration in small groups for clarification and elaboration on the study material (Ellis, 2010; Johnson, 2013). Moreover, there are other active learning pedagogies, which include visual-based instruction (Johnson et al., 2016), small group problem based learning, cooperative learning, debates, drama, role playing and simulation and peer teaching. One innovative approach in education delivery system is the “flipped classroom,” an educational technique that consists of two parts, interactive group learning activities inside the classroom and direct personal computer-based individual instruction outside the classroom (Bishop & Verleger, 2013). As such, work typically done as homework in the didactic model (e.g., problem solving, essay writing) is better undertaken in class with the guidance of the teacher. Listening to a lecture or watching videos is undertaken at home. Hence, the term flipped or inverted classroom is used (Herreid & Schiller, 2013). The essence of a flipped classroom is that the activities carried out during traditional class time and self-study time are reversed or “flipped” (Veeramani, Madhugiri & Chand, 2015). Approaches to undergraduate teaching have improved over the years as the scholarship of learning and teaching has provided evidence of what works to improve the outcomes. However, educational delivery approaches have shown little change in many disciplines and have remained the same for the majority of the sectors (Van Vliet, Winnips & Brouwer, 2015). The flipped class is flexible itself and can be tailored (Tetreault, 2013). Historically, the concept of flipped classroom started in early 1990s. General Sylvanus Thayer created a system at West Point in USA, where a set of learning materials was given to engineering students so that they obtained core content prior to attending class. The classroom space was then used for critical thinking and group problem solving (Musallam, 2011). Many credited the rejuvenation of this idea with the development of, and increased access to, educational technologies (Moffett, 2015). For instance, the School of Business at the University of Miami proposed an ‘inverted classroom,’ which had events that traditionally took place inside the classroom now taking place outside the classroom and vice versa (Lage, Platt & Treglia, 2000). In 2000, a conference paper entitled ‘The Classroom Flip’ was presented by J Wesley Baker and the phrase ‘flipping the classroom’ was coined. Baker described how flipping the classroom could allow the trainer to become the ‘guide on the side’ rather than the ‘sage on the stage’ (Baker, 2000). In a sense, this reversal also flips the Bloom's revised taxonomy because the lower level of cognitive work/knowledge acquisition is done by the students, while educators work interactively with the students to develop the higher forms of cognition (Figure 1). To date, this approach has attracted a large amount of attention in the HPE and a subsequent surge of literature. A comparison between the traditional learning and the flipped classroom in the Bloom's taxonomy [Color figure can be viewed at wileyonlinelibrary.com] Fundamentally, a flipped classroom encompasses two established elements of education, the recorded lecture (off campus learning) and active learning (on campus learning). Lectures are given as homework, as an aid to learning. Homework is important because it is a time where students can share their learning progress with their family, reflect on their learning, and review the material as well as the educator's feedback (Fulton, 2012). The key characteristics of a flipped classroom compared to a traditional classroom and other existing teaching methods are summarised in Table 1. It has been highlighted that the flipped classroom fits into the broader context of blended learning (Tetreault, 2013). Blended learning as defined by Staker is ‘a formal education program in which a student learns at least in part through online delivery of content and instruction with some element of student control over time, place, path, and/or pace and at least in part at a supervised brick-and-mortar location away from home’(Staker & Horn, 2012, p.3). The flipped classroom consists of a formal education program, and online learning as a mechanism of informal learning through educational video quizzes/games. The flipped classroom approach is connected between what the students learn online (e.g., video lecture) and what they learn face-to-face (e.g., in-class active case study), and vice versa, which is a common feature of blended learning (Tetreault, 2013). In principle, the flipped classroom assigns relatively low-level cognitive learning such as memorising and understanding, outside of the classroom and teaching in class is accomplished mostly through teacher-student interactions and cooperation between peers, thereby stimulating the students’ intellectual potential (Rui et al., 2017). The option to view video lectures (as an example) outside of classroom has beneficial effects for the learners as they can replay the videos as many times as needed to better understand the key concepts at their own pace. Furthermore, this allows each student to be able to comprehend the topics being covered to his/her satisfaction, whereas this might not be possible in the context of conventional teacher-centred teaching. This is an important pedagogical consideration for international students for whom English is their second language (Moraros, Islam, Yu, Banow & Schindelka, 2015). From the teacher's perspective, a flipped classroom setting makes it easier to engage students and empower them as active participants of their own learning. There are several theoretical constructs that are applicable for a flipped classroom. Two of these include: the technology acceptance model (TAM) (Davis, 1989) and the unified theory of acceptance and use of technology (UTAUT) (Venkatesh, Morris, Davis & Davis, 2003). These theoretical constructs provide a framework for the analysis and identification of relevant outcomes. We will outline how these two theories of flipped classroom learning can improve the learning outcomes such as student satisfaction and improved scores. TAM includes two theoretical constructs: (a) perceived usefulness and (b) perceived ease of use. These constructs are defined as "the degree to which a person believes that using a particular system would enhance his or her job performance" and "the degree to which a person believes that using a particular system would be free of effort", respectively (Davis, 1989, p320). The first theoretical construct relies on students’ prior knowledge, gained from the pre-class video lecture (for example), in enhancing their understanding (and overall learning performance) in the active in-class activities such as problem solving. The second theoretical construct is based on students' perceptions that if a flipped class room is more user friendly than the traditional teaching mode, then they would be more likely to accept it. The goal of the UTAUT model is to explain the intentions of a user to use a given information system and the subsequent behaviour of the user. The model is based on four primary constructs: 1) performance expectancy, 2) effort expectancy, 3) social influence, and 4) facilitating conditions (Venkatesh et al., 2003, p447). The first three constructs reflect the motivation of the users (i.e., students). The fourth construct reflects the characteristics of a flipped classroom setup when students engage with the pre-class materials that are uploaded on an e-learning portal. These material could be a video, an interactive presentation, a questionnaire or sometimes a recorded audio. With regard to these theoretical constructs, if students perceive that a flipped class room is user friendly and the academic environment facilitates their learning, then it will promote students' engagement, interactions and cooperation in learning, which will further improve their performance. There are potential advantages of a flipped classroom, including increased opportunities to provide individualised education to learners (Johnson, 2013; Kachka, 2012), increased student engagement with course material (Gross, Pietri, Anderson, Moyano-Camihort & Graham, 2015), and increased educator-student interaction, compared to a ‘performing’ lecture. The Kirkpatrick model of educational outcomes (Barry Issenberg, McGaghie, Petrusa, Lee Gordon & Scalese, 2005; Kirkpatrick & Kirkpatrick, 1994) comprises ‘learners’ reaction’ (to the educational experience); learning (modification of attitudes/perceptions and the acquisition of knowledge and skills); behaviour (self-reported changes in practice and observed changes in practice, including new leadership positions); and results (which refers to change at the level of the organisation) (Figure 2). For instance, regarding the 'results' outcome, the flipped classroom allows the teacher to gain advanced, real-time insight into how students learn and quickly identify and better address curriculum content that the students find most challenging. This insight can be used to better inform decisions with regard to effective curriculum organisation, structure and the delivery of future classes. Four levels of learning in Kirkpatrick's model [Color figure can be viewed at wileyonlinelibrary.com] The success of a flipped classroom approach relies on a number of assumptions. Stimulation of students’ interest in learning and guided self-study (Moraros et al., 2015), primarily depends on the opportunities to actively engage students in self-directed learning and encourage progressive improvement (Bergmann, Overmyer & Wilie, 2012; Moraros et al., 2015) in assessment performances. Thus, a flipped class will not support effective learning if students fail to engage with the assigned pre-class or in-class activities (Kachka, 2012), for reasons which might include poorly designed educational materials (e.g., long, poor audio quality) or students feeling ‘lost’ (Moffett, 2015). As such, a number of contextual and structural factors that can influence flipped classroom learning include resources (inputs to the program), activities (aspects of implementation), outputs (observable products of the completed activities) and outcomes (effects or impacts within various time frames) as depicted in the conceptual framework (Figure 3). Logic model of flipped class learning [Color figure can be viewed at wileyonlinelibrary.com] There are individual studies, which have evaluated flipped classroom in medical education, allied health education and health science education, using a pre-and post-test design or comparative designs to explore how learning outcomes are improved. Some studies showed positive outcomes with flipped classroom (Galway, Corbett, Takaro, Tairyan & Frank, 2014; Van Vliet et al., 2015), while others showed the opposite (Whillier & Lystad, 2015). For instance, a study on integrated flipped lectures with online teaching techniques assessed learning experiences and participation through active learning. The findings suggested that the students in the integrated flipped-online lectures had achieved an increase in active learning components compared to the group that were put in a didactic model (Galway et al., 2014). It is important to understand the factors that could have contributed to this difference. As an example, for balance of the safe learning environment (to be free from discomfort and fear) between the two groups of students, a comparability of the personality traits between the students in each group needs to be considered. On the other hand, another individual study, which assessed the effectiveness of flipped classroom in ophthalmology clerkship reported that the students in flipped classroom had more burden and pressure in preparing for the pre-class compared with the students in lecturer-based classroom group. Thus far, these published individual studies varied in design, sample size and outcome measures. It is unclear, if these findings would be generalised to other HPE. A non-Campbell systematic review of the flipped classroom reported how the flipped classroom has been applied in nursing education and the achieved outcomes associated with such teaching (Betihavas, Bridgman, Kornhaber & Cross, 2016). Due to the focus on a particular educational context (i.e., nursing or ophthalmology), the generalisability of their findings to other courses in undergraduate HPE is uncertain. Another non-Campbell collaborative systematic review, consisting of 82 studies reported on the effectiveness of flipped classroom in medical education where a pooled estimate of a subset of six experimental studies showed generally positive perceptions of the students to the flipped classroom. However, there were no significant changes in knowledge and skills (Cohen's d = −0.27 to 1.21, median: 0.08; Chen, Lui, & Martinelli, 2017). These systematic reviews, focused on a particular area (either nursing education or medical education) had a limited number of included studies, considerable variation in study designs, a lack of methodological quality assessment of the included studies, and the quality of evidence reported by these systematic reviews is poor. A systematic review which combines the results of interventions, using flipped classroom compared with alternative learning or traditional learning, will help us to make recommendations for the development and implementation of successful flipped classroom amongst health professionals. The current review also aims to serve as a reference for decision makers to support evidence-based approaches to flipped classroom in HPE. The primary objective of this systematic review is to assess the effectiveness of flipped classroom intervention for undergraduate health professional students on academic performance and course satisfaction. The influence of context in the design, delivery and outcomes of the flipped classroom interventions in undergraduate health professional education; The barriers and facilitators of flipped classroom learning effectiveness for undergraduate health professional students. Specifically, this review is designed to answer the following research questions: What are the effects of flipped classroom learning on undergraduate health professional students' academic performance? What are the effects of flipped classroom learning on undergraduate health professional students' course satisfaction? Do any moderator variables affect the effectiveness of flipped classroom learning on academic performance outcomes? Moderators will include (if data are available), study design, student related factors such as the amount of out-of-class preparation time, classroom availability and limited high speed internet access for rural and remote students, quality of interactive tools, and faculty related factors such as faculty members' preference to a more didactic approach. Randomised designs, which include individual-level randomised trials, cluster-level randomised trials and natural experiments, where assignment to treatment or control conditions is functionally random. Non-randomised designs, which include at least one treatment group and at least one comparison group, matching designs, two-group pre-post designs, regression discontinuity designs. We do not include qualitative research. We included all undergraduate health professional students, regardless of the type of healthcare streams (e.g., medicine, dentistry, nursing, pharmacy), duration of the learning activity (e.g., one or two semesters) or the country where the study is conducted. Any educational intervention that includes the flipped classroom as a teaching and learning activity in undergraduate programmes, regardless of the type of healthcare streams (e.g., medicine, dentistry, nursing, pharmacy) will be considered. To be included, a study must explicitly indicate that the teaching/learning activities for undergraduate students included in the flipped classroom, reversed classroom or flipping class, aiming to improve student learning and/or student satisfaction. Standard lectures and subsequent tutorial formats will not be considered as flipped classroom. Studies on flipped classroom methods among undergraduate or postgraduate students who are not from the healthcare streams (e.g., engineering, economics, computer science) will be excluded. We explored the impact of flipped classroom learning in undergraduate health professional students on academic related outcomes. The primary outcome is academic performance measured by examination scores, final grades or other formal assessment methods at immediate post-test. The secondary outcome is student satisfaction measured at immediate post-test using a self report scale, which may include the training institution's own format of assessing student satisfaction. Following the guidelines of the Campbell Collaboration (Kugley et al., 2016), in order to a of studies to review, an in this research will an of in the area and in related of and Collaboration of of of for on for and and and to in and of and and the available of of The following is an example of the of to professional In the final review, all used will be included so that they can be will be using the for the given so that they will include in of and in from the will be connected with within each and by between We will the information studies from to a balance of various approaches to flipped classroom learning while primarily on those that in most educational and are provided in 1. We will for the studies from the regardless of language or study and such as for will be to identify any relevant of of review and reference may also provide information about the used in their of published reviews relevant to the current study will be obtained and for to the included (and studies We will also the We will the key in the they have any studies in progress or research. will be by of the using and to of We will also review the reference of the relevant studies for any studies that have not been in the Two review and will the and to the for this of all that might the will be and for by and Any will be by and by to a review if We will with of the primary studies, where to study A & will be used to the study and a with the characteristics of studies will be of study setting of study participants group, at of the education duration of the flipped classroom, of intervention such as video lecture, lecture of the other interventions in to the education outcomes and secondary of outcome, used to outcome, time points of outcome Any information that the studies will be on variables related to the information that include study the of the intervention and how it is the characteristics of the the outcome variables and and contextual such as of and so The the for in order to in of studies is provided in of in the individual randomised trials will be at the study level by using the of & 2011). For designs, will use the of from the and of which of outcome of outcome of outcome and other of For most of the will answer the following with of of or of to make of of methodological quality will be by two and there is any it will be by taking a between the two a of the review will be to the We will present an overall of the evidence related to each of the main outcomes using the of and approach. The approach the quality of a of evidence as the to which one can be that an estimate of or is to the of a specific The quality of a of the consideration of within of of of and of et al., 2011). A level of evidence for the of will be from to very as part of the et al., We will not studies on the of of of are reported when the results of We to present all included studies and provide a of of with the potential of the review as well as of in the of the results the of the In trials, the of is a group, rather than an within to in a the data be as being and thus have to be A of analysis typically

Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC). Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions. Design: Systematic review secondary analysis. Setting/Subjects: RCTs of palliative care interventions. Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival. Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials. Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.

For ecology faculty members not directly involved in pedagogical research, it can be daunting to decide among the many new tools and approaches available to improve teaching and learning. Problem-based learning (Edens 2000), blended learning (Garrison and Kanuka 2004), case-based teaching (Herreid et al. 2011), active learning (Bean 2011), MOOCs (Daniel 2012), and flipping the classroom (Bergmann and Sams 2008, Bergmann and Sams 2012, Fulton 2012, Tucker 2012, Bishop and Verleger 2013, Herreid and Schiller 2013) are just a few of the new methods being evaluated and implemented in educational theory and practice. Flipping the classroom is the process of moving traditional lecture content teaching to videos watched by students outside the class, while simultaneously moving activities such as homework and group projects into the classroom (Bergmann and Sams 2008, 2012). At our university, replacement of traditional introductory biology lectures with recorded “talking head” videos in the late 1970’s and early 1980’s was an abysmal failure, one that damaged the reputation of our department long after the practice was abandoned. How does “flipping the classroom” differ from this? In what context might it make sense to move content delivery outside the classroom, while moving homework and group exercises into the traditional lecture period?

A View from the Frontline: Palliative and Ethical Considerations of the COVID-19 Pandemic.

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

IntroductionFlipped classroom refers to a teaching model where the lecture and homework elements of the class are reversed. Students develop knowledge and understanding during the pre-class session, and use the in-class time for active learning such as small group discussions, wherein they are expected to develop the skills of problem-solving (application) and critical thinking (analysis). An educational psychologist, Benjamin Bloom, proposed Bloom’s Taxonomy for the cognitive domain. According to this taxonomy, knowledge, and understanding have been considered to be lower-order cognitive skills (LOCS), while application (problem-solving), analysis (critical thinking), synthesis, and evaluation have been considered higher-order cognitive skills (HOCS). Only one study has reported that flipped classroom approach helps in the acquisition of HOCS such as application, analysis, synthesis, and evaluation. The present study aims to compare the flipped classroom model with the traditional lecture model and focuses particularly on the acquisition of HOCS such as application and analysis, by assessing the students using multiple-choice questions based on clinical vignettes.MethodsThe study was conducted in the Department of Physiology at Government Medical College, Bhavnagar. A total of 102 students in two groups, Group A (n=52) and Group B (n=50), participated in all the phases of the study. In the flipped classroom group, students watched the pre-recorded videos and studied standard textbooks, followed by a group discussion in the class. The traditional Lecture group attended the didactic lecture only. Topic I was taught to Group A using the flipped classroom model and to Group B using the traditional didactic lecture approach. Topic II was taught to Group B by using the flipped classroom method and to Group A using the traditional didactic lecture.Both groups of students were assessed after a gap of one week with multiple-choice questions based on clinical vignettes for checking the HOCS. These questions were designed based on Blooming Biology Tool (BBT).The feedback collected responses regarding the learning experience, perceived value of the flipped classroom, the course materials, the teaching process, and the evaluation system.ResultsThe students, who participated in the flipped classrooms, performed statistically better than those in the traditional lecture model (5.36 ± 1.69 vs. 4.94 ± 1.34) (p<0.05). The students strongly agreed that the flipped classroom method was an enjoyable way of learning: it enhanced their problem solving and analytical ability as well as developed their ability to work as team members and plan their own work. Students in both the flipped classrooms gave a similar perception indicated by the small effect size (r <0.3).ConclusionThe pre-class time of the flipped classroom model helps students remember the facts and understand the concepts (both lower-order cognitive skills), and uses the valuable in-class time to master the application of the concepts and critically analyze them (application and analysis being higher-order cognitive skills).

79 Background: Despite rigorous evidence of improved quality of life and longer survival, disparities in the utilization and quality of palliative and hospice care persist for racial and ethnic minority (Black and Latinx) patients with advanced lung cancer. To better understand drivers of palliative care and hospice inequities, this study evaluated the impact of psychosocial factors (e.g., lung cancer beliefs) on palliative and hospice care utilization among minority patients with cancer. Methods: This was a prospective cohort study of 99 patients with advanced lung cancer recruited at the Mount Sinai Hospital. At enrollment, minority and non-minority patients were asked questions about their sociodemographic, clinical, and the following psychosocial factors: medical mistrust, lung cancer beliefs, palliative care and hospice beliefs. Palliative care and hospice care utilization was abstracted from patients’ medical records. Bivariate analysis examined the association between independent factors (e.g., sociodemographic, lung cancer beliefs) and outcomes of palliative care consult and hospice care use (yes vs. no). Results: Of the 99 enrolled participants, 55 (55%) were minorities with a mean age of 65 years. 42% completed a palliative care consult and 26% utilized hospice care (26%). Palliative care utilization was associated with more favorable beliefs toward palliative care (p = 0.022) and hospice (p = 0.005) and lower levels of medical mistrust (p = 0.007). Majority of the sample was not refered to palliative (50%) or hospice care (61%); however patients refered were more likely to utilize care (p &lt; 0.001). Minority patients were more likely to receive a referral and schedule a palliative care consultation compared to non-minorities (p &lt; 0.001). Self-reported minority status did not predict differences in hospice care use. Conclusions: Minority patients with lung cancer were more likely to receive a palliative care referral and specialty level consultation when compared to non-minority patients. Higher levels of mistrust were a driver of not receiving palliative care. Patient referrals appear to be an important leverage point to help mitigate disparities in palliative and hospice care use. Future work to understand factors associated with palliative care use and the impact on minority patients is needed.

A diagnosis of cancer and subsequent therapies (surgery, radiation, chemotherapy) are known to result in negative physical symptoms (eg, pain, nausea, fatigue, shortness of breath, weight loss). In addition to physical symptoms, increased depression and anxiety are also common. These symptoms negatively impact both the patient diagnosed with cancer and their family caregivers. The combination of cancer therapies and unpleasant side-effects can be overwhelming for patients and families to navigate. Thankfully, supportive palliative care has been shown to improve the overall experience of those along this journey.1–3 In fact, specialty palliative care is considered the “gold standard” for all patients with advanced cancer.4 Unfortunately, this service is not readily available to all. The American Society of Clinical Oncology (ASCO) and the National Cancer Institute (NCI) recommend that cancer treatment be delivered concurrently with palliative care for patients with advanced cancer.4 This recommendation includes the use of a specialty interdisciplinary palliative care team early in the disease trajectory for both the patient and their family.4 Palliative care is defined as a holistic care approach provided by an interdisciplinary team to manage a patient’s physical, psychosocial, emotional, and spiritual needs.5,6 Over the past few years, progress has been made to include palliative care services alongside cancer care, in some areas, however, not all patients receive this benefit. Hui et al7 reported that 95% of NCI-designated oncology centers offered outpatient specialty palliative care services. While less than half (40%) of non-NCI-designated cancer centers offered these same services. NCI-designated cancer centers make up approximately 30% of US Hospitals.7 Even though specialty palliative care programs within cancer centers have increased, access remains a challenge at non-NCI, resource-deficit, or smaller cancer centers. Leaving most patients without access to these critical advanced services. With these restrictions and limited access to specialty services, how then are we to provide this critical service to our patients and families receiving care at most cancer care centers across the nation? One answer may be primary palliative care. Primary palliative care is a holistic approach to care by all care providers that incorporates palliative care principles within chronic disease management (eg, cancer) utilizing collaboration with specialty palliative care providers when needed.8,9 The focus is on addressing palliative care competences, such as symptom and pain management and goals of care conversations (eg, my choices my wishes). Support and training for primary palliative care is available to all primary care providers through national palliative care organizations (eg, Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the American Academy of Hospice and Palliative Medicine). The Center to Advance Palliative Care (https://www.capc.org) offers training for all members of the health care team with a focus on tools for practice and training. The Hospice and Palliative Nurses Association (https://advancingexpertcare.org) provides education to all members of the nursing team that focuses on communication and care of patients with advanced disease. Lastly, the American Academy of Hospice and Palliative Medicine (http://aahpm.org) provides training with a primary focus on doctors and advanced care providers. In summary, the gold standard of care is to provide concurrent palliative care for patients with advanced cancer based upon the recommendations of ASCO and NCI. Additionally, the benefits of palliative care for cancer patients and families have been realized through evidence. However, specialty palliative care teams remain a scarce resource for many non-NCI oncology centers. To combat this issue, basic palliative care training and education should be provided to all oncology care providers so that primary palliative care can be integrated to fill this gap for patients and families. Financial Disclosure The authors have no funding or conflicts of interest to disclose.

110 Background: Palliative care trials face implementation barriers. We describe challenges encountered in a pilot trial of early specialty palliative care for patients with pancreatic cancer. Methods: We conducted a mixed-methods pilot randomized controlled trial of early specialty physician-led palliative care in advanced pancreatic cancer. Recently diagnosed patients with borderline, locally-advanced, or metastatic pancreatic cancer and their caregivers (total N=60) were recruited from clinic at a comprehensive cancer center and randomized (2:1) to receive monthly specialty palliative care visits for 3 months in addition to standard oncology care vs. standard oncology care alone. Feasibility assessments included enrollment and intervention completion rates. Acceptability and perceived effectiveness were assessed via drop-out rates and semi-structured participant interviews. Results: The enrollment target was reached after 50 weeks, with a randomized: approached rate of 27%. Mean patient age was 63 (SD 11) and 50% were male. Mean caregiver age was 62 (SD 12), 47% were male, and 80% were the spouse or partner of a patient. 70% of participants in the intervention group completed at least one specialty palliative care visit and 15% completed 3 palliative care visits within the 3-month time period. Two patients and 3 caregivers withdrew, and 4 patients died prior to 3 months. Enrollment barriers included patients not planning to continue receiving care from a participating oncologist and feeling too overwhelmed at the time of diagnosis to consider research participation. In semi-structured interviews, patients and caregivers noted that long travel times to the cancer center, difficulty scheduling palliative care visits at a convenient time, and lengthy study assessments posed burdens. Oncologists and palliative care physicians recommended more in-person communication between clinicians and tailoring palliative care visit content and schedules to match patient needs. Conclusions: Future palliative care intervention trials must consider implementation challenges related to recruitment, retention, intervention fidelity, and participant burden. Clinical trial information: NCT01885884.

OPINION article Front. Oncol., 11 April 2016Sec. Women's Cancer Volume 6 - 2016 | https://doi.org/10.3389/fonc.2016.00083

e24125 Background: Palliative care promotes timely symptom management, and care planning and improves quality of life in oncology patients. About 60% of community oncology practices sampled in 2015 had outpatient palliative care. This study updates estimates of palliative care resources in community oncology. Methods: Questions from the 2022 Landscape Assessment of National Cancer Institute Community Oncology Research Program (NCORP) (funding provided by 2UG1CA189824) assessed the availability of specialist palliative care providers and ancillary care services, including utilization of advanced practice providers (APPs). Descriptive statistics describe availability of providers and services. Multivariable logistic regression was used to identify practice characteristics associated with palliative care specialist availability in 2022. Differences in rates of palliative care specialists, outpatient palliative care, APPs and patient portal use between 2015 and 2022 assessment results were assessed using Chi-Square tests, assuming independent time snapshots of general population characteristics. Results: Most community oncology practices sampled in 2015 had palliative care specialists (76%) and 62% of practices reported having outpatient palliative care. Of the 259 non-pediatric exclusive NCORP practice groups included in the 2022 analyses (Table 1), significantly more had palliative care specialists (86%; p = 0.003) and offered palliative care in the outpatient setting (76%; p = 0.001). Most practices utilized APPs (92%) and had a patient portal (95%), while only 41% had a survivorship clinic. Multivariable analyses demonstrated practices with more adult oncology providers (OR = 1.03, p = 0.039) and those with a designated survivorship clinic (OR = 3.16, p = 0.001), were significantly more likely to have specialty palliative care in the outpatient setting. Conclusions: More practices reported availability of palliative care specialists and outpatient services in community oncology practices in 2022 compared to 2015, with more oncology providers being associated with increased odds of having outpatient specialty palliative care in 2022. Smaller community oncology practices with fewer providers may need support to expand their capacity to provide palliative care. [Table: see text]

Palliative care (PC) use patterns may have changed in recent years due to increased adoption of telehealth and the availability of more advanced practice clinicians who specialize in PC delivery. To describe changes in the use of specialty PC during the last year of life among Medicare beneficiaries who had cancers with poor prognoses (cancers that commonly caused death, rare cancers with high mortality rates, or solid tumors with concurrent nonlymphatic metastases; hereinafter termed poor-prognosis cancers). This retrospective cohort study includes all US Medicare fee-for-service beneficiaries who died from poor-prognosis cancers between January 1, 2018, and December 31, 2023, and received care in hospital and outpatient settings. Encounters with a PC specialist. The primary outcome was the proportion of decedents with any specialty PC encounter in their last year of life. Secondary outcomes included mean number of PC encounters among decedents with at least 1 encounter with a PC specialist and telehealth use. PC specialists were clinicians who self-identified as a PC specialist or were clinicians with 80% or more of their Medicare encounters focused on PC. The cohort included 1 508 103 decedents (mean [SD] age, 79.6 [8.0] years; 54.6% male) with poor-prognosis cancers. Between 2018 and 2023, the proportion of decedents with at least 1 PC encounter increased from 29.84% to 37.21% (adjusted change, 7.21 [95% CI, 6.30-8.12] percentage points; relative change, 24.2%). The proportion who received outpatient PC increased from 10.66% to 20.56% (adjusted change, 9.41 [95% CI, 8.33-10.48] percentage points; relative change, 88.2%). In 2023, 22.84% of all decedents received PC from advanced practice clinicians vs 15.60% by self-designated PC physicians and 9.92% by other physicians. Telehealth was used for 18.2% of all outpatient palliative care encounters in 2023. Decedent characteristics associated with not receiving specialty PC included older age, lower income, and living in nonmetropolitan areas. In this cohort study of decedents who had poor-prognosis cancers, an increasing proportion received any specialty PC. Advanced practice specialists were the most common clinician type who delivered specialty PC, and telehealth was used for a substantial proportion of outpatient visits. Despite these changes, only a minority of patients received specialty PC, and low use of specialty PC among certain subpopulations persisted, suggesting that different strategies are needed to overcome these barriers.

Background:Older adults with Alzheimer's disease and related dementias can benefit from palliative care (PC). Whether specialty and nonspecialty PC have the same effect on outcomes is unclear. We examined the effects of these 2 interventions on comfort, symptom management, satisfaction with care, and potentially burdensome transitions, including hospital admission, emergency department visit, intensive care unit admission in the end-of-life, and in-hospital death.Methods:This PRISMA-adherent systematic review involved a search of PubMed, Medline, EMBASE, Cochrane Library, ProQuest, and CINAHL for studies published from January 1, 2013, to November 4, 2024. Primary studies that reported at least one of the 7 patient-level outcomes were included: Comfort Assessment in Dying with Dementia (CAD-EOLD), Symptom Management at the End-of-Life (SM-EOLD), Satisfaction with Care at the End-of-Life in Dementia (SWC-EOLD), hospital admissions, emergency department visits, intensive care unit admissions, and in-hospital death.Results:Nineteen articles involving 142,772 participants were included. The evidence, comprising studies of adequate to strong quality, revealed that both specialty and nonspecialty PC did not differ in terms of comfort, symptom management, or satisfaction with care. However, both approaches significantly reduced the likelihood of intensive care unit admissions and in-hospital deaths. Specialty PC was associated with decreased emergency department visits (OR 0.53, 95% CI 0.28–1.00; I2=86%).Conclusions:Future research is needed to understand factors influencing PC interventions that can improve comfort, symptom management, and care satisfaction for these individuals and their families.

Underlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and to integrate palliative care education into the ICU. To achieve this goal, 3 models for incorporating palliative care in the ICU have been proposed: the integrative model (education in primary palliative care skills for ICU clinicians); the consultative model (access to palliative care specialists); and the mixed model that uses both of these approaches simultaneously.1,2 It is increasingly clear that a mixed model, in which the education and deployment of palliative care specialists is combined with the education of all clinicians in basic principles of palliative care, is the optimal approach to address the diverse range of palliative care needs in the ICU.2